STEP THREE OF TEN DONE!

Whoo hoo, I did my Skype interview with the midwife assessors in Canada today! Step one was applying, step two was applying for the Accelerated Option (now called the “Accelerated Stream”, which conjures pleasing images of babbling brooks), step three was the interview. Step ten is “and I finish packing the U Haul and drive into the sunset.”

I have no idea what step four through nine might be.

Anyway, it was kind of fun once I got rolling. The interviewers were a midwife from BC and another from Alberta. The BC midwife has a three month old and actually ASKED if I minded if she nursed during the interview. I hope my uproarious laughter and “Of COURSE not!” was taken in the good humor in which it was intended.

I answered a lot of questions about GBS management, largely with it as an example of my informed consent process. Generally speaking, I follow CDC standards, and for the occasional mom who wants to avoid antibiotics, I’m OK with risk factor treatment-for prolonged rupture of membranes, meaning more than 18 hours. The other indications are being less than 37 weeks and maternal fever during labor, whereupon we’re going to the hospital anyway.

My only absolute is that I can’t/won’t deliberately not treat a positive result. I picked that up from an OB who is also a lawyer (raise your hand if THAT breaks your head), who said in a specific situation, “If you weren’t gonna treat it, you shouldn’t have tested for it!”, and went on to explain that it’s legally very difficult to defend that course of action. The scenario I want to avoid now is for a mom to blithely accept the GBS screen, to be shocked and surprised by a positive result, and then try to argue me out of antibiotics. That being said, I HAVE become more accepting of alternative treatments.

Interestingly, my practice will be limited compared to what I can do now. I can do contraceptive counseling but not the actual prescription, and won’t put in IUDs. The BC midwife said that it’s an opportunity for midwives to pursue in the future. I offered, if and when that happens, I can be a resource for that. Even if I don’t put in an IUD for years, it’s a little like riding a bike. For the medical types reading this, the CNM who taught me the most about IUDs said, “It’s like putting in IV’s. You do about ten and you’re good to go.”

I also won’t be able to manage postpartum mood disorders. I may actually miss that; it’s a particular area of interest for me, and it’s quite satisfying when the lowest dose of Zoloft works effectively and we wean off in three to six months. I should hasten to add that I don’t just throw Zoloft at any and all depressed and/or anxious moms, but when it’s clearly indicated, it’s a great thing. Much like most interventions. They’re great when they’re indicated.

Another difference in practice is that because midwives ARE so well integrated into the system, they are more bound by their standards of care; ie, the list of reasons for consultation is clearly spelled out.

I’m more than willing to give up these things to be able to do home and hospital birth.

They asked a few questions about how my management style of postpartum hemorrhage has changed, something I addressed in the narratives. For about three years I had this crazy retained placenta/postpartum hemorrhage karma. I was seriously ready to hire a witch doctor to rid me of it. Turns out I didn’t need to, I just made a conscious decision to begin offering Pitocin if the placenta hadn’t delivered by 30 minutes, and haven’t had one since.

I DID have a few occasions of planning for active 3rd stage management, most commonly in women who were anemic. In each of these cases, well, we ended up sorta forgetting. Baby came, placenta came, recovery proceeded. An hour later I (or someone) say, “Wait a minute. Weren’t we supposed to give you Pitocin?” Whereupon we all shrug our shoulders and marvel at the minimal blood loss. Interventions are great when they’re indicated. And only when they’re indicated.

An interesting series of questions had to do with how I would handle moms who flatly refuse a clearly indicated transfer. I took a while to actually answer their question; those of you who know me know that I tend to give long winded answers. They wanted to know what I would do here, not what I’ve done in the past, which seems like an odd question. I won’t know until I’m there and faced with the situation. I said I’d need to know what the guidelines are, and the degree of support I’d receive from my colleagues and collaborators. Also, at the end of the interview, I asked pointed questions about malpractice risk, because that’s a consideration. More on that later.

I concluded with saying that most women with that degree of resistance to needed medical care tend to self select out of my care. Before that happens, ideally, I’ve had a chance to ask the mom, “Under what conditions ARE you willing to go to the hospital?” Because everyone has a line somewhere, and it’s usually sometime before death or disability. The nuances of this kind of decision making are part of the reason that I’m hired. If I’m too conservative for her, well, there are other midwives out there whose limits are more liberal than mine. Fortunately, my journey has taught me to let go of pejoratives. My feelings aren’t hurt if someone chooses another midwife or leaves my care, nor do I feel like a smug hero if someone comes to me from another midwife because my standards are more liberal.

I ended with a question of my own: In the US, 89% of obstetricians have been sued. I’d wager that the other 11% have been in practice for less than 10 years and will eventually be sued. About 15% of midwives have been sued. Did they have numbers of the frequency of lawsuits in Canada?

No, they didn’t, just that their number is WAY less than that. And I heard much the same thing that happens here: sometimes a midwife can follow standards to the letter, but if a bad outcome occurs, sometimes the parents sue because they need the money for long term care. I suspect that some of the reason they have fewer lawsuits is because there is a universal health care system.

At the end of the interview I talked for a few minutes to the program director about time lines. Much to my befuddlement, NOW I may not be moving until March of next year. The program starts in January, but I can do it online; I actually have to physically be there to begin a six week intensive in April, which will be followed by taking the board exam.

*sigh* Not sure what I’ll do yet. I’ll likely ponder various possibilities in another post.

And yes, I was pantsless.

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